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  1. Home
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  3. Anesthesia for Otolaryngologic Surgery
  • Cited by 2
Publisher:
Cambridge University Press
Online publication date:
November 2012
Print publication year:
2012
Online ISBN:
9781139088312
DOI:
https://doi.org/10.1017/CBO9781139088312
Subjects:
Anesthesia, Intensive Care, Pain Management, Medicine, Surgery
Information

Book description

Anesthesia for Otolaryngologic Surgery offers a comprehensive synopsis of the anesthetic management options for otolaryngologic and bronchoscopic procedures. Authored by world authorities in the fields of anesthesiology and otolaryngology, both theoretical concepts and practical issues are addressed in detail, providing literature-based evidence wherever available and offering expert clinical opinion where rigorous scientific evidence is lacking. A full chapter is dedicated to every common surgical ENT procedure, as well as less common procedures such as face transplantation. Clinical chapters are enriched with case descriptions, making the text applicable to everyday practice. Chapters are also enhanced by numerous illustrations and recommended anesthetic management plans, as well as hints and tips that draw on the authors' extensive experience. Comprehensively reviewing the whole field, Anesthesia for Otolaryngologic Surgery is an invaluable resource for every clinician involved in the care of ENT surgical patients, including anesthesiologists, otolaryngologists and pulmonologists.

Reviews

'This addition to the body of anesthesia literature is much welcomed … Contributions from both anesthesiologists and surgeons add strength to this book.'

Source: Canadian Journal of Anesthesia

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Contents

Page 2 of 2

Contents
  • Chapter 19 - Anesthesia for carotid body tumor resction
    pp 186-194
  • View abstract

    Summary

    The majority of septoplasties and rhinoplasties are performed on healthy patients in the outpatient setting; however, occasionally patients present with medical comorbidities or obstructive sleep apnea (OSA). These surgeries can be performed with local anesthesia and sedation or general anesthesia with an LMA or endotracheal tube. The indication for surgery may be purely cosmetic, post trauma, reconstructive after tumor resection or to improve nasal breathing. Many nasal procedures can successfully be performed under local anesthesia with sedation. Operative and recovery times have been shown to be shorter for patients undergoing surgery with local anesthesia with sedation compared with general anesthesia. Bleeding is one of the biggest complications of nasal surgery. Minimization of intraoperative blood loss allows the surgeon to have an operative field which he can visualize well. The main intraoperative concern includes the minimization of bleeding with use of vasoconstrictors and submucosal epinephrine, controlled hypotension and a smooth emergence.
  • Chapter 21 - Anesthesia for parotid surgery
    pp 203-209
  • View abstract

    Summary

    Functional endoscopic sinus surgery is among the most challenging of ENT procedures for a variety of reasons including the need for immobility, hemostasis, and, especially, gentle emergence from anesthesia. Anesthesiologists have contributed significantly, using anesthetic techniques to mitigate intraoperative hemorrhage into the surgical field, thus significantly improving visualization of the surgical field. Functional endoscopic sinus surgery (FESS) strives to enable direct examination in situ with subsequent correction of encountered chronic changes and barriers which limit sinus drainage and aeration. The use of supraglottic airway (SGA) over endotracheal tubes (ETT) appears additionally advantageous, providing reduced incidence and severity of coughing intraoperatively and during emergence. Propofol/remifentanil total intravenous anesthesia (TIVA) with spontaneous respiration (PRTSR) is considered by some an optimal strategy to avoid emergence problems and provide flexibility, and minimize nausea, vomiting, and estimated blood loss (EBL), while ensuring rapid induction and emergence.
  • Chapter 22 - Anesthesia for maxillary, salivary gland, mandibular and temporomandibular joint surgery
    pp 210-219
  • View abstract

    Summary

    Transsphenoidal pituitary resection is a common surgical procedure that offers unique challenges to the anesthesiologist. Generally, the transsphenoidal approach to the sella region can be divided into two techniques: (1) the sublabial approach which involves an incision made beneath the upper lip into the gum and subsequently through the septum and (2) the transnasal approach which involves dissection through the nasal cavity wall using microsurgical or endoscopic instruments inserted through the nostrils. The heterogeneity of the patient population and their medical condition requires a fundamental knowledge of the nature of pituitary disease and management. Understanding the specific demands of the surgical technique allows the anesthesia provider to facilitate the procedure and increase the efficacy of the intervention. Additionally, predicting and managing the peri- and postoperative complications allows the anesthesiologist to maximize the safety of the patient.
  • Chapter 23 - Anesthesia for face transplantation
    pp 220-227
  • View abstract

    Summary

    The terms neck dissection and laryngectomy describe a wide variety of surgical procedures that attempt to remove a cancer and its main route of spread. Neck dissection is commonly performed during laryngectomy for cancer to prevent and treat any local spread of the primary disease. A careful airway evaluation is an essential part of preparation for a patient undergoing laryngectomy with neck dissection. The treatment of laryngeal cancer has three primary goals: tumor removal, prevention of spread and recurrence, and preservation of organ function (phonation and swallowing) where possible. Neck radiation changes can make airway management difficult as its presence is an independent predictor of failure for both bag-mask ventilation and GlideScope intubation. Systolic blood pressure variation of the arterial line tracing can help guide fluid replacement. Alternatively a central line, at a different location from the neck dissection, can be used.
  • Chapter 25 - Anesthesia for ENT laser surgery
    pp 237-244
  • View abstract

    Summary

    Otolaryngologic flap reconstructive surgery, while lengthy, risky and complex, can be performed with a high degree of safety. Flaps can be categorized based on their blood supply. For head and neck surgery patients, a group of patients have been well characterized as gaining the most benefit from free flap reconstructions. The anesthetic management includes careful planning of difficult airway issues such as tracheostomy if the airway is compromised, considerations to positioning, understanding of surgical sites, choice of intraoperative monitoring, considerations related to the length of surgery and thermoregulation, flap perfusion considerations, planning postoperative care and level of care. This is in addition to considerations related to coexisting morbidities in this elderly population, who commonly present with tobacco and alcohol abuse. Clear communication with otolaryngology colleagues will help greatly for proper planning and execution of these considerations, helping to ensure a favorable outcome.
  • Chapter 26 - Anesthesia for laryngoplasty
    pp 245-254
  • View abstract

    Summary

    There are several specific issues that significantly affect the anesthetic management for patients undergoing thyroid surgery. In addition to the general considerations pertaining to anesthesia, specific attention should be directed to the assessment of thyroid function, the size and location of the thyroid gland, its relationship to the trachea and adjacent vascular structures, and the co-existence of a multiple endocrine neoplasia. Hyperparathyroidism due to an adenoma or hyperplasia is the most common presenting symptom of multiple endocrine neoplasia 1 syndrome. Patients at risk of iatrogenic hypoparathyroidism should have ionized calcium levels monitored postoperatively until calcium levels demonstrate that parathyroid function is intact. Primary hyperparathyroidism may result from benign parathyroid adenoma, multiple gland hyperplasia and carcinoma of the parathyroid glands. Clinical signs include carpopedal spasm during cuff inflation, facial twitching by tapping over the facial nerve at the parotid gland, and a prolonged QT interval on the ECG.
  • Chapter 27 - Anesthesia for tracheotomy
    pp 255-262
  • View abstract

    Summary

    The obstructive sleep apnea (OSA) patient presenting for OSA surgery presents a number of challenges to the anesthesiologist. OSA is diagnosed by clinical history and an overnight sleep study or polysomnography (PSG). PAP treatment attempts to maintain a competent airway through the application of continuous positive airway pressure (CPAP), bi-level positive pressure (BiPAP) or auto-titrating positive pressure (APAP). The three anatomic areas that can contribute to OSA as a result of increased nasal resistance include the alar cartilage/nasal valve area, the septum and the turbinates. These patients may have a number of cardiac and respiratory comorbidities as well as very challenging airways. Consideration should be given to optimization of medical comorbidities preoperatively, careful airway management, and minimization of sedating pain medications intraoperatively. Postoperatively airway edema, hemorrhage, and respiratory complications are a concern and the patient should be recovered in a monitored setting until they return to their baseline.
  • Chapter 28 - Anesthesia for the management of subglottic stenosis and tracheal resection
    pp 263-270
  • View abstract

    Summary

    The perioperative anesthetic management of carotid body tumor resection includes a comprehensive preoperative airway assessment, optimization of patient comorbidities, and identification of symptoms pointing to secreting tumors. The goals of intraoperative hemodynamic management are to maintain normal baseline hemodynamics, avoiding extreme swings in blood pressure and heart rate. Whether regional or general anesthesia is used, the goals of perioperative management are to preserve stable hemodynamics and maintain end-organ perfusion, to prepare for resuscitation of acute major blood loss, to utilize monitoring modalities to identify, avoid, and manage cerebral ischemia, and to provide a smooth controlled emergence. Internal carotid artery clamping, reconstruction or sacrifice may be required for large grade III tumors or when the internal carotid artery is inadvertently injured. In the postoperative period, complications should be anticipated, diagnosed, and promptly managed. Patients undergoing bilateral carotid tumor surgery should be continuously monitored in an intensive care environment postoperatively.
  • Chapter 29 - Anesthesia for otologic and neurotologic surgery
    pp 271-296
  • View abstract

    Summary

    The location of Zenker's diverticulum along with the inherent risks of aspiration at any given stage of surgery (pre-, intra- or postoperative periods) adds an element of unique difficulty in the anesthetic approach to these patients. This chapter explores the anesthetic considerations for this unique procedure. The surgical procedure is generally curative and a majority of the patients live symptom-free for the rest of their lifetime. A main concern during the induction period is to safely secure the airway without increasing the risk of aspiration. While regurgitation and aspiration may occur during induction of anesthesia and during intubation, they might still happen even after successful uneventful intubation. Pertinent perioperative evaluation should include detailed cardiovascular and nutritional status evaluation and optimization. Perforation of Zenker's diverticulum may occur during a difficult intubation, or during blind placement of a nasogastric tube.
  • Chapter 30 - Anesthesia for diagnostic bronchoscopic procedures
    pp 297-308
  • View abstract

    Summary

    The paired parotid glands are the largest among the three major salivary glands in the human body. The parotid gland is encapsulated between the superficial and deep layers of the parotid gland fascia (PGF). This chapter discusses the surgical treatment and anesthesia of sialolithiasis. Airway management after parotidectomy with radical neck dissection can be a challenging situation due to aggravating factors like previous neck interventions, radiation therapy, large fluid shift, intraoperative airway manipulation, swollen tissue and residual anesthetic effect. Ductal stone formation and ductal stenosis are common causes of obstructive salivary diseases of the parotid glands. Sufficient anesthetic depth and patient immobility are usually achieved by a balanced anesthetic technique employing relatively large doses of opioid and inhalational agents. Light anesthesia and patient movement lead to serious complications, especially in the absence of neuromuscular blockade.
  • Chapter 31 - Anesthesia for therapeutic bronchoscopic procedures
    pp 309-320
  • View abstract

    Summary

    This chapter focuses on non-traumatic maxillary procedures and endoscopic maxillary sinus surgery. Successful surgery involves open dialog between the anesthesiologist, ENT surgeon, and at times the plastic surgeon. Salivary gland resection poses technical challenges to both the surgeon and the anesthesiologist. The anesthetic management of these procedures mainly involves preservation of motor function of the face. Salivary gland resection is an example of the integrated efforts of both surgeon and anesthesiologist. The chapter focuses on the surgery of the mandible and temporomandibular joint (TMJ). Surgery for the mandible can range from biopsy to radical mandibular resection. An example of an anesthetic management for reconstructive mandibular cancer surgery is discussed in the chapter. TMJ arthroscopy is an effective minimally invasive technique to reduce pain and improve the mandibular range of motion that can be done safely on an outpatient basis.
  • Chapter 32 - Anesthesia for pediatric otolaryngologic surgery
    pp 321-336
  • View abstract

    Summary

    This chapter outlines anesthetic considerations for face transplantation procedure based on the experience of two hospitals where the first face transplants in the United States took place as well as preliminary data from three international centers (personal communication). Careful examination of a patient's airway is critical since it dictates intraoperative airway management plan. The goals and principles of intraoperative fluid management in face transplantation are similar to any other long surgical procedure involving micro-vascular free flaps. Airway management in cases where the composite graft involves maxillary or mandibular structures may present a significant challenge: the forces associated with direct laryngoscopy for intubation could conceivably cause damage to incompletely healed bony structures. The duration and complexity of the face transplant operation requires participation of multiple teams, including more than one anesthesia team.
  • Chapter 33 - Anesthesia for reconstructive airway surgery in pediatrics
    pp 337-345
  • View abstract

    Summary

    During panendoscopy, the anesthesiologist and surgeon must share the airway, with different objectives. The anesthesiologist must deliver oxygen, remove carbon dioxide, provide anesthesia and protect the airway from soiling or aspiration. The surgeon requires an immobile, unobstructed surgical field and adequate time for diagnostic evaluation and intervention. Some patients requiring panendoscopy will present with critical airway obstruction and in these circumstances the safest approach is to proceed to elective tracheostomy under local anesthesia prior to any further endoscopic evaluation. Ventilation techniques can be considered in terms of open and closed systems. A closed system implies ventilation via a cuffed endotracheal tube (ETT). An open system without an ETT is more commonly used for panendoscopy. Panendoscopy is a brief yet highly stimulating procedure that requires deep anesthesia, obtunded hemodynamic reflexes, an immobile surgical field and rapid emergence with early return of protective airway reflexes.

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